Multiuser immersive virtual reality simulation for interprofessional sepsis recognition and management.

INTRODUCTION: Sepsis is a leading cause of pediatric mortality. While there has been significant effort toward improving adherence to evidence-based care, gaps remain. Immersive multiuser virtual reality (MUVR) simulation may be an approach to enhance provider clinical competency and situation awareness for sepsis. METHODS: A prospective, observational pilot of an interprofessional MUVR simulation assessing a decompensating patient from sepsis was conducted from January to June 2021. The study objective was to establish validity and acceptability evidence for the platform by assessing differences in sepsis recognition between experienced and novice participants. Interprofessional teams assessed and managed a patient together in the same VR experience with the primary outcome of time to recognition of sepsis utilizing the Situation Awareness Global Assessment Technique analyzed using a logistic regression model. Secondary outcomes were perceived clinical accuracy, relevancy to practice, and side effects experienced. RESULTS: Seventy-two simulations included 144 participants. The cumulative odds ratio of recognizing sepsis at 2 min into the simulation in comparison to later time points by experienced versus novice providers were significantly higher with a cumulative odds ratio of 3.70 (95% confidence interval: 1.15-9.07, p = .004). Participants agreed that the simulation was clinically accurate (98.6%) and will impact their practice (81.1%), with a high degree of immersion (95.7%-99.3%), and the majority of side effects were perceived as mild (70.4%-81.4%). CONCLUSIONS: Our novel MUVR simulation demonstrated significant differences in sepsis recognition between experienced and novice participants. This validity evidence along with the data on the simulation's acceptability supports expanded use in training and assessment.

Characteristics of patients with atrial fibrillation treated with direct oral anticoagulants and new insights into inappropriate dosing: results from the French National Prospective Registry: PAFF.

AIMS: Since the introduction of direct oral anticoagulant (DOAC) for atrial fibrillation (AF) therapy, inappropriate and/or underdosing of these drugs has been a major clinical challenge. We evaluated the characteristics of patients with AF treated with inappropriate and low-dose DOACs. METHODS AND RESULTS: Patients with AF treated with inappropriate and low-dose DOACs from October 2021 to December 2021 were evaluated from the French National Prospective Registry (PAFF). We evaluated 1890 patients with AF receiving DOACs (apixaban 55%, dabigatran 7%, and rivaroxaban 38%). Inappropriate dosing was noted in 18% of the population. Patients with appropriate dosing had less comorbidities: younger age (75 ± 10 vs. 82 ± 8 years old, P < 0.0001), reduced chronic renal failure (26 vs. 61%, P < 0.0001), and lower CHA2DS2VASc and HASBLED scores (3 ± 2 vs. 4 ± 3, P < 0.0001; 2 ±1 vs. 2 ± 2, P < 0.0001), respectively. In multivariate analysis, older age (P < 0.0001) and a higher CHA2DS2VASc score (P = 0.0056) were independently associated with inappropriate DOAC dosing. Among 472 patients (27%) treated with low-dose rivaroxaban or apixaban, 46% were inappropriately underdosed. Patients inappropriately underdosed were younger (82.3 ± 8.4 vs. 85.9 ± 5.9 years, P < 0.0001) with less chronic renal disease (47 vs. 98%, P < 0.0001). However, these patients had higher rates of prior haemorrhagic events (18 vs. 10%, P = 0.01), clopidogrel use (11 vs. 3%, P = 0.0002), and apixaban prescription (74 vs. 50%, P < 0.0001). CONCLUSION: Within this large registry, DOACs were associated with inappropriate dosing in 18% of cases. Independent predictors of inappropriate dosing were high CHA2DS2VASc scores and older age. Moreover, 46% of patients treated with low-dose DOACs were inappropriately underdosed and more frequently in patients treated with apixaban.

Development and Implementation of Augmented Reality Enhanced High-Fidelity Simulation for Recognition of Patient Decompensation.

INTRODUCTION: Simulation is a core aspect of training and assessment; however, simulation laboratories are limited in their ability to visually represent mental, respiratory, and perfusion status. Augmented reality (AR) represents a potential adjunct to address this gap. METHODS: A prospective, observational pilot of interprofessional simulation assessing a decompensating patient was conducted from April to June 2019. Teams completed 2 simulations: (1) traditional training (TT) using a manikin (Laerdal SimJunior) and (2) AR-enhanced training (ART) using a manikin plus an AR patient. The primary outcome was self-assessed effectiveness at the assessment of patient decompensation. Secondary outcomes were attitudes toward and adverse effects during the AR training. RESULTS: Twenty-one simulation sessions included 84 participants in headsets. Participants reported improved ability to assess the patient's mental status, respiratory status, and perfusion status (all P < 0.0001) during ART in comparison to TT. Similar findings were noted for recognition of hypoxemia, shock, apnea, and decompensation (all P ≤ 0.0003) but not for recognition of cardiac arrest (P = 0.06). Most participants agreed or strongly agreed that ART accurately depicted a decompensating patient (89%), reinforced key components of the patient assessment (88%), and will impact how they care for patients (68%). Augmented reality-enhanced training was rated more effective than manikin training and standardized patients and equally as effective as bedside teaching. CONCLUSIONS: This novel application of AR to enhance the realism of manikin simulation demonstrated improvement in self-assessed recognition of patient decompensation. Augmented reality may represent a viable modality for increasing the clinical impact of training.

Association between overactive bladder treatment and falls among older adults.

AIMS: To analyze the risk of falls associated with Overactive bladder (OAB), and the effects of OAB treatment on falls among older adult Medicare fee-for-service enrollees. METHODS: Population based retrospective longitudinal cohort design study using 5% Medicare claims between 2006 and 2010. Patients with a diagnosis of OAB (ICD 9: 596.51); Urinary Incontinence (ICD 9: 788.3); Urinary incontinence, unspecified (ICD 9: 788.30); Urge incontinence (ICD 9: 788.31); Mixed incontinence (male, female) (ICD 9: 788.33); Urinary frequency (ICD 9: 788.41); Nocturia (ICD 9: 788.43); or Urgency of urination (ICD 9: 788.63) were identified and followed retrospectively for 2 years. Falls was the main outcome of the study. Using logistic regressions, we analyzed the association between OAB and falls; and the protective effect of OAB treatment on falls. Propensity score and instrumental variable were used to minimize bias. RESULTS: We identified 33 631 Medicare enrollees (mean age = 77.8 years, sd = 7.6) with OAB. Higher proportion of OAB patients had falls, compared to those without OAB (11% vs 7%, P < 0.001). Diagnosis of OAB was associated with higher odds of falls (OR = 1.59; 95% CI = 1.53, 1.65) compared to those without OAB. Fourteen percent of OAB patients received OAB treatment. Treatment for OAB was associated with lower odds of falls (OR = 0.88; 95% CI = 0.80, 0.98) compared to those OAB patients who were not treated. CONCLUSIONS: Older adults with OAB experience increased risk of falls. Treatment for OAB may reduce this risk. These findings emphasize the need to effectively identify and treat OAB in older adults.

Comparative effectiveness of prostate cancer treatments for patient-centered outcomes: A systematic review and meta-analysis (PRISMA Compliant).

BACKGROUND: In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients. METHODS: We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms "prostate cancer," "localized," "outcomes," "mortality," "health related quality of life," and "complications" to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias. RESULTS: Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term. CONCLUSION: Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

Influence of the mode of management of acute myocardial infarction on the inducibility of ventricular tachyarrhythmias with programmed ventricular stimulation after myocardial infarction.

BACKGROUND: Programmed ventricular stimulation (PVS) is a technique for screening patients at risk for ventricular tachycardia (VT) after myocardial infarction (MI), but the results might be difficult to interpret. OBJECTIVES: To investigate the results of PVS after MI, according to date of completion. METHODS: PVS results were interpreted according to the mode of MI management in 801 asymptomatic patients: 301 (group I) during the period 1982-1989, 315 (group II) during 1990-1999, and 185 (group III) during 2000-2010. The periods were chosen based on changes in MI management. Angiotensin-converting enzyme (ACE) inhibitors had been given since 1990; primary angioplasty was performed routinely since 2000. The PVS protocol was the same throughout the whole study period. RESULTS: Group III was older (61 +/- 11 years) than groups I (56 +/- 11) and II (58 +/- 11) (P < 0.002). Left ventricular ejection fraction (LVEF) was lower in group III (36.5 +/- 11%) than in groups I (44 +/- 15) and II (41 +/- 12) (P < 0.000). Monomorphic VT < 270 beats/min was induced as frequently in group III (28%) as in group II (22.5%) but more frequently than in group I (20%) (P < 0.03). Ventricular fibrillation and flutter (VF) was induced less frequently in group III (14%) than in groups I (28%) (P < 0.0004) and II (30%) (P < 0.0000). Low left ventricular ejection fraction (LVEF) and date of inclusion (before/after 2000) were predictors of VT or VF induction on multivariate analysis. CONCLUSIONS: Induction of non-specific arrhythmias (ventricular flutter and fibrillation) was less frequent than before 2000, despite the indication of PVS in patients with lower LVEF. This decrease could be due to the increased use of systematic primary angioplasty for MI since 2000.

[Wine: Good for all cardiovascular diseases?]. / Le vin : bon pour toutes les pathologies cardiovasculaires ?

UNLABELLED: Beneficial effects of wine are mainly due to polyphenol components with a major role for resveratrol. Moderate wine consumption decreases cardiovascular mortality. Very favorable effects in coronary artery disease and cholesterol. Deleterious effects in systemic hypertension and dilated cardiomyopathy. RECOMMENDATION: 1 to 2 drinks (10 to 20g of alcohol) per day.

Localizing the critical isthmus of postinfarct ventricular tachycardia: the value of pace-mapping during sinus rhythm.

BACKGROUND: Most postinfarct ventricular tachycardias (VTs) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. Various techniques based on conventional electrophysiology and/or detailed three-dimensional (3D) reconstruction of the VT circuit are used to unmask this isthmus. OBJECTIVE: The purpose of this study was to assess pace-maps (PMs) to identify postinfarct VT isthmuses. We hypothesized that an abrupt change in paced QRS morphology may be used to identify a VT isthmus and be targeted for successful ablation. METHODS: High-density 3D PMs were matched to the subsequent 3D endocardial reentrant VT activation mapping in 10 patients (8 men; age 70.7 ± 10.8 years) who underwent successful postinfarct VT ablation. At each pacing site in a given patient, the 12-lead ECG recorded during pacing was compared to that of VT, with the resulting matching percentage (up to 100% for perfect matches) allocated to this point to generate color-coded PMs. RESULTS: With respect to VT isthmuses, the best percentages of matching were found in the exit zones and isthmus exit part (89% ± 8% and 84% ± 7%, respectively) and the poorest adjacent to scar border in the outer entrance zones (23% ± 28%), in the entrance zones (39% ± 34%), and in the entrance part of the isthmus (32% ± 26%). The color-coded sequence (from the best to the poorest matching sites) on the PMs revealed figure-of-eight pictures matching the VT activation time maps and identifying VT isthmuses. CONCLUSION: Pace-mapping is useful for unmasking VT isthmuses in patients with well-tolerated postinfarct endocardial reentrant VTs.

Atrial flutter or fibrillation is the most frequent and life-threatening arrhythmia in myotonic dystrophy.

BACKGROUND: Several arrhythmias were reported in myotonic dystrophy (MD). OBJECTIVES: To evaluate the prevalence of atrial fibrillation (AF) and atrial flutter (AFL) in MD and the clinical consequences. METHODS: One hundred sixty-one patients, mean age 41 ± 14 years, were referred for a type 1 MD. All patients were asymptomatic except four patients and followed during 5 ± 4 years. Electrocardiogram (ECG), echocardiography assessing left ventricular ejection fraction, and Holter monitoring were obtained and repeated. RESULTS: Twenty-seven patients (17%) presented sustained (>1 hour) AF (n = 15) or AFL (n = 12); two of them presented syncope-related 1/1 AFL. In one of them, 16 years of age, cardiac defibrillator was implanted for a diagnosis of ventricular tachycardia, but the true diagnosis was established after inappropriate shocks. AFL ablation was performed in five patients, but four developed AF. The other seven patients with AFL developed AF. During the follow-up, 22 patients died (14%) from cardiac and respiratory failure; eight patients with AF/AFL died (30%) while only 14 without AF/AFL died (10%; P < 0.01). Univariate analysis indicated that age >40 years (death: 48 ± 14 vs 40 ± 8 in alive patients), abnormal ECG, and occurrence of AF/AFL were significant factors of death. At multivariate analysis, AF at ECG (odds ratio: 3.12) and age >40 (odds ratio: 3.14) were the sole independent variables predicting death. CONCLUSIONS: AF and AFL were frequent in MD and increased mortality. AFL could present as 1/1 AFL with a poor tolerance and a risk of misdiagnosis despite frequent conduction disturbances. This arrhythmia could explain wide QRS tachycardia occurring in MD and interpreted as VT.

Cancer patients' trade-offs among efficacy, toxicity, and out-of-pocket cost in the curative and noncurative setting.

BACKGROUND: When making treatment decisions, cancer patients must make trade-offs among efficacy, toxicity, and cost. However, little is known about what patient characteristics may influence these trade-offs. METHODS: A total of 400 cancer patients reviewed 2 of 3 stylized curative and noncurative scenarios that asked them to choose between 2 treatments of varying levels of efficacy, toxicity, and cost. Each scenario included 9 choice sets. Demographics, cost concerns, numeracy, and optimism were assessed. Within each scenario, we used latent class methods to distinguish groups with discrete preferences. We then used regressions with group membership probabilities as covariates to identify associations. RESULTS: The median age of the patients was 61 years (range, 27-90 y). Of the total number of patients included, 25% were enrolled at a community hospital, and 99% were insured. Three latent classes were identified that demonstrated (1) preference for survival, (2) aversion to high cost, and (3) aversion to toxicity. Across all scenarios, patients with higher income were more likely to be in the class that favored survival. Lower income patients were more likely to be in the class that was averse to high cost (P<0.05). Similar associations were found between education, employment status, numeracy, cost concerns, and latent class. CONCLUSIONS: Even in these stylized scenarios, socioeconomic status predicted the treatment choice. Higher income patients may be more likely to focus on survival, whereas those of lower socioeconomic status may be more likely to avoid expensive treatment, regardless of survival or toxicity. This raises the possibility that insurance plans with greater cost-sharing may have the unintended consequence of increasing disparities in cancer care.

1:1 atrial-flutter. Prevalence and clinical characteristics.

UNLABELLED: Little is known about the epidemiology of 1:1 atrial flutter (AFL). Our objectives were to determine its prevalence and predisposing conditions. METHODS: 1037 patients aged 16 to 93 years (mean 64±12) were consecutively referred for AFL ablation. 791 had heart disease (HD). Patients admitted with 1/1 AFL were collected. Patients were followed 3±3 years. RESULTS: 1:1 AFL-related tachycardiomyopathy was found in 85 patients, 59 men (69%) with a mean age of 59±12 years. The prevalence was 8%. They were compared to 952 patients, 741 men (78%, 0.04), with a mean age of 65±12 years (0.002) without 1:1 AFL. Factors favoring 1:1 AFL was the absence of HD (35 vs 23%, 0.006), the history of AF (42 vs 30.5%)(0.025) and the use of class I antiarrhythmic drugs (34 vs 13%)(p<0.0001), while use of amiodarone or beta blockers was less frequent in patients with 1:1 AFL (5, 3.5%) than in patients without 1:1 AFL (25, 15%) (p<0.0001, 0.03). The failure of ablation (9.4 vs 11%), ablation-related complications (2.3 vs 1.4%), risk of subsequent atrial fibrillation (AF) (20 vs 24%), risk of AFL recurrences (19 vs 13%) and risk of cardiac death (5 vs 6%) were similar in patients with and without 1:1 AFL. CONCLUSIONS: The prevalence of 1:1 AFL in patients admitted for AFL ablation was 8%. These patients were younger, had less frequent HD, had more frequent history of AF and received more frequently class I antiarrhythmic drugs than patients without 1:1 AFL. Their prognosis was similar to patients without 1:1 AFL.

A stepwise approach to the management of postinfarct ventricular tachycardia using catheter ablation as the first-line treatment: a single-center experience.

BACKGROUND: The occurrence of ventricular tachycardia (VT) after myocardial infarction is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators are recommended. Catheter ablation of VT is currently recommended only as an adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of these patients, however, remains unknown. The aim of the present study was to evaluate this strategy. METHODS AND RESULTS: Between January 2002 and December 2011, 189 patients with cardiomyopathy underwent 259 VT ablations in our center. Forty-five patients (mean age, 65.2±9.6 years; 91% men) with a history of myocardial infarction and mean left ventricular ejection fraction of 39.7±9.7% matched the study criteria and were included in this analysis. Acute success was obtained in 40 of 45 patients (88.9%). During a follow-up, on the basis of our stepwise algorithm (using acute success, repeat electrophysiological study, and recurrence of VT), 19 of 45 patients (42.2%) underwent implantable cardioverter-defibrillators implantation. During a median follow-up of 4.5 (interquartile range, 2.1-7.0) years, all-cause mortality occurred in 14 of 45 patients (31.1%). Using multivariate Cox regression analysis, age (hazard ratio, 1.13; 95% confidence interval, 1.03-1.22; P=0.007) was the only independent predictor of mortality, whereas implantable cardioverter-defibrillators implantation was not (hazard ratio, 0.54; 95% confidence interval, 0.18-1.64; P=0.28) CONCLUSIONS: Our results suggest that a stepwise approach to the management of VT with ablation as a first-line treatment in postinfarct patients presenting with VT might be a reasonable option. Further studies are required to confirm these results.

Age-related prognosis of syncope associated with a preexcitation syndrome.

BACKGROUND: Syncope in Wolff-Parkinson-White syndrome (WPW) is without relationship with WPW or reveals a poorly tolerated arrhythmia. Electrophysiologic study (EPS) is recommended. The purpose of the study was to evaluate the influence of the patient's age on the causes and prognosis of syncope. METHODS: A total of 98 patients, mean age 35 ± 18 years, with WPW were admitted for syncope. Note that 29 were aged between 9 and 19 years (mean 15 ± 3) (children and teenagers/group I), 45 between 20 and 49 years (mean 34 ± 8) (adults/group II), and 24 between 50 and 70 years (mean 60 ± 8) (elderly/group III). EPS consisted of atrial pacing and programmed atrial stimulation in control state and after isoproterenol. RESULTS: Potentially malignant form (rapid conduction in accessory pathway >240 beats/min in control state or >300 beats/min after isoproterenol and atrial fibrillation [AF] induction) was more frequent in group I (34%) than in groups II (7%) (P < 0.002) and III (0%) (P < 0.001). Orthodromic atrioventricular reentrant tachycardia (AVRT) and AF were induced as frequently in groups I (59, 34%), II (47, 15.5%), and III (54, 17%). AVRT was induced in all but one patient with malignant form. EPS was as frequently negative in groups I (27.5%), II (44%), and III (37.5%). Natural follow-up (mean 8 ± 6 years) indicated a favorable prognosis, only related to AVRT induction. Induced AF was without significance. CONCLUSIONS: Data in syncope and WPW syndrome depended on age: electrophysiological malignant form was frequent in children/teenagers, rare in adults, and absent in elderly. AVRT, the main cause of syncope, was as frequent in all ranges of age. AF's induction alone had no significance. Final prognosis was favorable.

Cycle length characteristics differentiating non-sustained from self-terminating ventricular fibrillation in Brugada syndrome.

AIMS: Limited information is available on self-terminating (ST) ventricular fibrillation (VF). Understanding spontaneous fluctuations in VF cycle length (CL) is required to identify arrhythmia that will stop before shock. Using Brugada syndrome (BS) as a model, the purpose of the study was to compare ST-VF and VF terminated by electrical shock and to look for spontaneous fluctuations in ventricular CL. METHODS AND RESULTS: Occurrence of ST-VF and VF was studied in 53 patients with 46 VF episodes: (i) spontaneously, (ii) during defibrillation threshold testing, (iii) during programmed ventricular stimulation (PVS). Fifteen presented ST-VF (average duration 25 s): 11 during PVS, 1 during defibrillation threshold testing, and 3 spontaneously (at device interrogation). Self-terminating ventricular fibrillation was compared with 31 VFs terminated by electrical shock. Mean ventricular CL was longer (192.5 ± 22 vs. 149 ± 19 ms) (P < 0.0001) and CL became longer or did not change in ST-VF (187 ± 28 vs. 200 ± 25 ms) (first vs. last CL)(NS) in contrast with progressively shorter CL in electrical shock-terminated VF (177 ± 14.5 vs. 139 ± 12 ms) (first vs. last CL before electrical shock) (P < 0.0001). Ventricular fibrillation had more CL variability (average 16.4 ± 6.5 ms) for the first 50 beats than ST-VF (average 4.08 ± 2) (P < 0.0001). Cycle length range for the first 50 beats was 9.6 ± 1 ms for ST-VF and 44 ± 15 for VF (P < 0.002). CONCLUSION: Self-terminating ventricular fibrillation in BS was not rare (28%). Ventricular CL was longer and progressively increased or did not change in ST-VF compared with electrical shock-terminating VF. Cycle length variability and CL range could differentiate VF and ST-VF within the first 50 beats. These parameters should be considered in the algorithms for VF detection and termination.

Incidence and prognostic significance of spontaneous and inducible antidromic tachycardia.

AIMS: Orthodromic atrioventricular reentrant tachycardia (ORT) is the most common arrhythmia at electrophysiological study (EPS) in patients with pre-excitation. The purpose of the study was to determine the clinical significance and the electrophysiological characteristics of patients with inducible antidromic tachycardia (ADT). METHODS AND RESULTS: Electrophysiological study was performed in 807 patients with a pre-excitation syndrome in control state and after isoproterenol. Antidromic tachycardia was induced in 63 patients (8%). Clinical and electrophysiological data were compared with those of 744 patients without ADT. Patients with and without ADT were similar in term of age (33 ± 18 vs. 34 ± 17), male gender (68 vs. 61%), clinical presentation with spontaneous atrioventricular reentrant tachycardia (AVRT) (35 vs. 42%), atrial fibrillation (AF) (3 vs. 3%), syncope (16 vs. 12%). In patients with induced ADT, asymptomatic patients were less frequent (24 vs. 37%; <0.04), spontaneous ADT and spontaneous malignant form more frequent (8 vs. 0.5%; <0.001) (16 vs. 6%; <0.002). Left lateral accessory pathway (AP) location was more frequent (51 vs. 36%; P < 0.022), septal location less frequent (40 vs. 56%; P < 0.01). And 1/1 conduction through AP was more rapid. Orthodromic AVRT induction was as frequent (55.5 vs. 55%), but AF induction (41 vs. 24%; P < 0.002) and electrophysiological malignant form were more frequent (22 vs. 12%; P < 0.02). The follow-up was similar; four deaths and three spontaneous malignant forms occurred in patients without ADT. When population was divided based on age (<20/≥20 years), the older group was less likely to have criteria for malignant form. CONCLUSION: Antidromic tachycardia induction is rare in pre-excitation syndrome and generally is associated with spontaneous or electrophysiological malignant form, but clinical outcome does not differ.

Missing diagnosis of preexcitation syndrome on ECG: clinical and electrophysiological significance.

UNLABELLED: Electrocardiographic criteria of preexcitation syndrome are sometimes not visible on ECG in sinus rhythm (SR). The purpose of the study was to evaluate the significance of unapparent preexcitation syndrome in SR, when overt conduction through accessory pathway (AP) was noted at atrial pacing. METHODS: Anterograde conduction through atrioventricular AP was identified at electrophysiological study (EPS) in 712 patients, studied for tachycardia (n=316), syncope (n=89) or life-threatening arrhythmia (n=55) or asymptomatic preexcitation syndrome (n=252). ECG in SR at the time of EPS was analysed. RESULTS: 78 patients (11%) (group I) had a normal ECG in SR and anterograde conduction over AP at atrial pacing; 634 (group II) had overt preexcitation in SR. Group I was as frequently asymptomatic (35%) as group II (35%), had as frequently tachycardias, syncope or life-threatening arrhythmia as group II (43, 5, 2% vs 43, 13, 8%). AP was more frequently left lateral in group I (57%) than in group II (36%)(p<0.001). AV re-entrant tachycardia, atrial fibrillation (AF), antidromic tachycardia were induced as frequently in group I (54, 18, 10%) as in group II (54, 27, 7%). Malignant forms (induced AF with RR intervals between preexcited beats <250ms in control state or <200ms after isoproterenol) were as frequent in group I (11.5%) as II (14%). CONCLUSIONS: The frequency of unapparent preexcitation syndrome represents 11% of our population with anterograde conduction through an AP and could be underestimated. The risk to have a malignant form is as high as in patients with overt preexcitation syndrome in SR.

Prior experiences of racial discrimination and racial differences in health care system distrust.

PURPOSE: Factors contributing to racial differences in health care system distrust (HCSD) are currently unknown. Proposed potential contributing factors are prior experiences of racial discrimination and racial residential segregation. METHODS: Random digit dialing survey of 762 African American and 1267 white adults living in 40 US metropolitan statistical areas. Measures included the Revised Health Care System Distrust scale, the Experiences of Discrimination scale, metrics of access to care, sociodemographic characteristics, and the level of racial residential segregation in the city (using the isolation index). RESULTS: In unadjusted analyses, African Americans had higher levels of HCSD, particularly values distrust, and greater experiences of discrimination. Experience of discrimination was also strongly associated with HCSD. Adjusting for sociodemographic characteristics, health care access, and residential segregation had little effect on the association between African American race and overall HCSD or values distrust. In contrast, adjusting for experiences of racial discrimination reversed the association so that distrust was lower among African Americans than whites (odds ratio 0.53; 95% confidence interval, 0.33-0.85 for the overall measure). The Sobel test for mediation was strongly significant (P<0.001). CONCLUSIONS: Higher HCSD among African Americans is explained by a greater burden of experiences of racial discrimination than whites. Reasons for higher distrust among whites after adjusting for experiences of racial discrimination are not known. Efforts to eliminate racial discrimination and restore trust given prior discrimination are needed.

Is ablation of atrial flutter always safe?

BACKGROUND: Radiofrequency ablation of typical atrial flutter is largely used and is considered as safe. The purpose of the study was to evaluate the prevalence and the causes of severe adverse event (AE) following atrial flutter ablation. METHODS: Ablation of typical flutter was performed by conventional method with an 8-mm-tip electrode catheter, a maximum power of 70 W, and a maximum target temperature of 70° for 60 seconds in 883 patients, (685 males and 198 females aged from 18 to 93 years [64 ± 11.5]; 664 had heart disease [HD]). RESULTS: AE occurred in 44 patients (5%). AE was life threatening in 14 patients: poorly tolerated bradycardia (transient complete atrioventricular block [AVB] or sinus bradycardia [SB] <40 beats per minute) associated with cardiac shock and acute renal failure in five patients, tamponade (n = 1), bleeding leading to death (n = 1), various AE-related deaths (n = 2), ventricular tachycardia-related death (n = 1), definitive complete AVB (n = 3), and right coronary artery occlusion-related complete AVB (n = 1). Less serious AE occurred in 30 patients: transitory major SB or second- or third-degree AVB (n = 23), bleeding (n = 4), transient ischemic attack (n = 1), and various AE (n = 2). Most of the bradycardia was related to ß-blockers or other antiarrhythmic drugs used to slow atrial flutter. Factors of AE were female gender (36% vs 22%, P < 0.02) and the presence of ischemic (P < 0.03) or valvular HD (P < 0.01). CONCLUSIONS: AE following atrial flutter ablation occurred in 5% of patients. Most of them are avoidable by control of anticoagulants and arrest of rate-control drugs used to slow the rate of atrial flutter.

Showing up channels for postinfarct ventricular tachycardia ablation.

The number of scar-related ventricular tachycardia (VT) ablation procedures is increasing worldwide. This is certainly due to the ever growing number of patients implanted with an implantable cardioverter defibrillator in whom an ablation procedure may be required to better control the ventricular arrhythmia burden, but is also likely related to our better understanding of the arrhythmias mechanisms as well as the improvement of the mapping techniques during the last 15 years. Most VTs, especially those arising after myocardial infarction, depend on a critical isthmus. Defining precisely the critical isthmus of postinfarct VT may be challenging, particularly when the arrhythmia is poorly tolerated. In the literature, there are extensive data concerning the value of conventional electrophysiological techniques, especially entrainment mapping in association with postpacing interval measurements, regarding the identification of postinfarct VT isthmuses. There are, however, other--sometimes emerging--approaches to image critical postinfarct VT channels. We have summarized these, reviewing data from the published literature as well as our own experience.